Endometriosis and pregnancy: The illusion of recovery

The objective of this study was to investigate the feelings and experiences of infertile women with deep infiltrating endometriosis during and after a first pregnancy achieved by in-vitro fertilization (IVF). We conducted a qualitative monocentric study between May and November 2020. Semi-structured interviews were undertaken with infertile women with deep infiltrating endometriosis who achieved a first pregnancy by IVF and delivered at least two years prior to the interview. Data analysis was performed using an inductive approach to identify recurrent categories and themes. Fifteen interviews were conducted to reach data saturation. Pregnancy appeared to improve all components of the experience of endometriosis that were explored (psychological and physical well-being, social relationships, professional life, and sexuality). This improvement was only temporary and all symptoms and negative aspects of the women’s quality of life reappeared after a variable period.


Introduction
Although endometriosis affects approximately 10% of women of childbearing age, its natural history is still debated [1,2]. It is commonly accepted that endometriosis is a disease that progresses inconsistently and slowly [3,4]. Recent studies, in particular imaging studies, suggest that continuous amenorrhea induced by hormonal treatments can limit the progression of deep endometriosis [5]. This also appears to be verified for amenorrhea due to pregnancy [5][6][7][8]. The underlying pathophysiological mechanisms are not entirely clear, but could involve the hormonal environment, in particular the increase in progesterone levels leading to luteal transformation, decidualization, and atrophy of the ectopic endometrium [9]. The interruption of retrograde menstruation has also been suggested as a pathophysiological explanation [10,11]. The supposedly positive impact of pregnancy on endometriosis lesions has led health professionals to recommend pregnancy as a treatment for endometriosis for almost a century [12,13]. Paradoxically, there is little research investigating the evolution of painful symptoms during and after pregnancy [13]. In 2018, Alberico et al. conducted a retrospective study involving 131 women with endometriosis. The authors found that while the women were indeed symptom-free during and immediately after delivery, 84% had a recurrence of moderate or severe pain symptomatology two years after delivery [14]. These quantitative data, although modest, appear to contradict the age-old myth of pregnancy as a treatment for endometriosis. Nevertheless, there are various reasons to suggest that pregnancy remains a uniquely special period for women with endometriosis: first, because of the difficulty in achieving pregnancy, since endometriosis is often associated with infertility; second, because of the lull in the painful symptoms; and finally, because of the complications of pregnancy, which are more frequent in women with endometriosis [15]. The objective of this study was to investigate the feelings and experiences of infertile women with deep infiltrating endometriosis during and after a first pregnancy obtained by invitro fertilization (IVF).

Method
We conducted a single-center qualitative study between May and November 2020 at the assisted-reproduction center of La Conception Hospital (Marseille, France). The study had previously received approval from the ethics committee of the University of Aix-Marseille (2020-07-05-07). All participants gave written consent after having been thoroughly informed orally and in writing about the terms of the study.
The inclusion criteria were: age between 18 and 43 years; deep infiltrating endometriosis suspected on pelvic magnetic resonance imaging (MRI) or diagnosed surgically (stages III and IV of the revised American Society for Reproductive Medicine (rASRM) classification [16]); IVF management with achievement of a first pregnancy and birth of a child who is still alive and healthy; and presence of at least one symptom immediately before IVF (dysmenorrhea, dyspareunia, or chronic pelvic pain). Exclusion criteria were: delivery less than two years or more than 10 years before the start of the study; no follow-up for more than one year in our center; poor understanding of French; or refusal to participate in the study.
Individual, in-depth, semi-structured interviews were conducted in person, by telephone, or by videoconference by a single investigator (A.V.). Signed consent was requested from participants before the interview began. The expected duration of the interviews announced to the participants was 30 minutes to one hour. A semi-structured interview guide composed of open-ended questions concerning the experience of endometriosis during IVF treatment, during pregnancy, and after delivery enabled the investigator to conduct each conversation in a semi-structured manner. Each interview was recorded and immediately transcribed verbatim, removing any information that might identify the participant. The recording was then deleted.
The data collected was coded by conducting a micro-analysis of each interview and was analyzed using an inductive approach based on a thematic analysis specific to qualitative research methodology. The coding data were compared and analyzed throughout the study in order to enrich the interview guide as needed. The study was stopped when no new data emerged during two consecutive interviews (indicating that data saturation had been achieved). The codes were then grouped and organized to create categories, which were then grouped into themes.

Results
Data saturation was achieved after 15 interviews. The women who agreed to participate were on average 37 ± 5 years of age at the time of the interview and had given birth on average 6 ± 2 years earlier ( Table 1). Of these women, 13 of 15 had had laparoscopic endometriosis surgery before pregnancy. All patients had at least one painful symptom (dysmenorrhea, dyspareunia, or chronic pelvic pain) immediately before pregnancy. Two interviews were conducted in person, one by videoconference, and 12 by telephone. The results of the interviews are presented in three sections: 1) endometriosis and IVF management; 2) disappearance of symptoms during pregnancy and immediately after pregnancy; and 3) recurrence of symptoms.

Experience of endometriosis during IVF management
3.1.1. Discontinuation of hormonal treatment. Invariably, discontinuation of contraception at the time of planned pregnancy was accompanied by an increase in pain. Several women described the ambivalence between the desire for pregnancy and the desire to resume hormonal treatment to combat painful symptoms. Pain was often identified as the main factor precipitating the abandonment of attempting to conceive naturally.

IVF, endometriosis, and social and professional life.
During the interviews, IVF treatment was often described as a social and professional hindrance in addition to the symptoms of endometriosis. Some women who already had to justify regular absenteeism from work because of painful symptoms described the fear of being dismissed or sidelined during their IVF course.
Participant 10: "My employer was making remarks to me, 'still absent', 'ah you're extending the time off work. . .' yet it was a woman." Some women also reported almost complete avoidance of social situations to avoid having to justify their absence. 3.1.3. Infertility, dyspareunia, and sexual life. Many women described sexuality as a taboo subject within the couple because of dyspareunia. The pregnancy project was also often described as destabilizing for the couple's equilibrium, with resumption and often planning of intercourse despite the pain. The women described their own anticipatory anxiety and the guilt of their partners. Conversely, at the time of the IVF treatment, the partner's involvement in the attempt at pregnancy was experienced as an element that strengthened the couple's cohesion.

Experience of symptom resolution during pregnancy and immediately after pregnancy
3.2.1. Lull and hope for recovery. Invariably, the women described the period of pregnancy as a period of lull in the symptoms of endometriosis, leading to a very positive experience despite the occurrence of pregnancy complications for more than half of the participants. This lull was often interpreted as a cure. Most of the women explained this belief as having been encouraged by a health professional or by information from the Internet presenting pregnancy as a treatment for endometriosis. This feeling of healing persisted after childbirth, and the women interviewed often said that this was justification for not taking hormone treatment. In addition, still following the idea of a cure, some patients said that they had persisted for a long time in attempting to achieve a second spontaneous pregnancy when the first had required IVF.

Social and professional normalization.
Women often reported that the improvement in symptoms during and immediately after pregnancy allowed them to resume activities that promoted a normalization of social life. In addition, the new status of pregnant woman or mother was described by the patients as an opportunity to conform to the norm. The entourage that had been distanced during the IVF process was, on the contrary, very present during the pregnancy and after the birth. Several patients also described that the period immediately after their maternity leave had been marked by new professional aspirations, either by the construction of more ambitious projects than before or by the idea of finding a professional field that was more benevolent towards their illness.

Calmness within the couple.
Consistently, patients described a marked improvement in interactions with their partners during and immediately after pregnancy. Several explanations were given: on the one hand, the disappearance of painful symptoms and, on the other hand, the feeling of having won a victory for both of them and the relief of achieving a pregnancy following the IVF procedure. On the other hand, most of the women described a decline in their sexuality, often attributed to the disappearance of spontaneity in intercourse following the infertility process.
Participant 10: "the IVF treatments destroyed certain things, the quality of sexual relations in particular, but strengthened other things in our couple."

Experience of the recurrence of symptoms
3.3.1. The resurgence of symptoms. The women consistently described that, after a period that varied in length but generally exceeded one year, their symptoms had gradually reappeared. The most frequently reported comments were regarding marked feelings of disappointment or disillusionment, which were related to the conviction that the pregnancy had allowed endometriosis to be cured definitively. The women described this period of gradual reappearance of symptoms very negatively. Several of them mentioned forgetting of the symptoms or denial of the disease during the lull period. The regret of not having resumed hormonal treatment after the pregnancy, often despite the advice of health professionals, was also expressed.
Participant 6: "You hope to have relief, but the relief for me was short-lived. You think maybe it will come back, but you forgot how bad the pain was. In fact, the pain before the pregnancy was more acceptable. When the pain became more intense again, (. . .) I even discussed a hysterectomy."

Social and professional disillusionment.
Most of the women described a return to almost the same social situation as before the pregnancy, often with social avoidance. Some women verbalized the difficulties they had encountered in making their family and friends, who thought they were cured, understand the recurrence of painful symptoms.

Participant 2: "It's been forgotten, clearly we don't talk about it at all. Endometriosis is still associated with infertility, and I have had children, so for them it means that I am cured."
The women also most often described a feeling of professional limitation, with the renunciation of projects that had been developed immediately after the pregnancy. Only the few patients who specifically pursued a reorientation towards an environment sympathetic to their illness reported an improvement in their professional life.

Lassitude and inconsistent partner support.
More than half of the women interviewed mentioned a deterioration in their relationship with their partner some time after the birth when the pain was on the rise. Often, women said that they had felt their partners' weariness of the symptoms and sometimes their disinterest or disinvestment in their illness.
Although only a few women had separated from their partners after delivery, the majority had already discussed the subject of divorce or separation.

Discussion
To our knowledge, this article represents the first qualitative study ever conducted about the feelings and experiences of infertile patients with endometriosis during and after a first pregnancy obtained by IVF. Inductive analysis of the interviews enabled us to construct a chronological scheme of the experience of the disease during this period. Our results suggest that during pregnancy and for a variable length of time after pregnancy, women have the momentary illusion of being cured of endometriosis. This illusion is explained in part by the lull in painful symptoms, but it is also maintained by the medical discourse, which frames pregnancy as a treatment for endometriosis. This cognitive phenomenon sometimes extends to forgetting or denying the disease, which, according to the women interviewed for this study, justifies the absence of resumption of hormonal treatment after childbirth, despite the advice of health professionals. After a variable length of time, the resurgence of symptoms is experienced very negatively by the women: first as a disappointment or disillusionment with the prospect of a cure, then by resignation and a renunciation of plans for a normal life.
Our study focuses on infertile women who have undergone IVF and achieved pregnancy. Some data in the literature have already established that endometriosis and endometriosisinduced infertility have a negative impact on quality of life [17,18]. The qualitative data we present allow us to explore the changes that take place precisely when infertility treatments have worked, and patients are pregnant. Our results are indeed in favor of an improvement during the pregnancy following IVF but suggest that this improvement is only temporary. Only quantitative data based on questionnaires should clarify whether quality of life is durably improved after pregnancy, but our results do not seem to suggest this. The interviews deliberately address very little about surgical treatment, even though most of our patients had undergone surgery prior to IVF according to an integrated approach already described in the literature [19,20]. It is likely that this integrated approach for endometriosis-associated infertility has an impact that should be explored to determine which of surgery or IVF has the greatest influence on patient experience. Several of our results also showed how these changes in patients' experiences make it difficult to resume hormone treatment after pregnancy. Several data in the literature suggest that this treatment is important to reduce the symptoms and progression of endometriosis [5,21]. Our study highlights the need to better inform patients of the importance of this medical treatment after childbirth even in the absence of symptoms.
In 2018, Leeners et al. conducted a systematic review of the literature regarding the effect of pregnancy on endometriosis [13]. Although the data were derived from a limited number of studies, some of which were not recent and all of which were retrospective and involved a small number of patients, it appears that the majority of lesions decrease in size during pregnancy. The authors nevertheless highlight that the evolution of endometriosis lesions is unpredictable, with progression in some women, and that very little research has been conducted on the long-term evolution after pregnancy. Millischer et al. conducted a retrospective study in 2019 involving 21 patients (67 deep endometriosis lesions) who had never undergone surgery and who had an MRI before and after pregnancy (with an interval of 20 ± 8 months between the two MRIs) [6]. The authors report a decrease in the mean volume of all lesions. Another retrospective study conducted by our team in 2019 on patients with rectal endometriosis lesions, eight of whom had a pregnancy, reported more mixed results for a longer duration between MRIs (51 ± 26 months), with regression noted for only one patient [5].
From a histological point of view, although there is a rationale for regression of endometriosis lesions during pregnancy due to decidualization of the ectopic endometrium and atrophy of the epithelium covering the lesions, the scientific literature is rather in favor of an inhomogeneous response of the lesions [13,22]. Indeed, decidualization is an inconstant phenomenon and is initially responsible for an increase in lesion size before being associated with regression [23][24][25]. Similarly, depending on the histological studies, atrophy, fibrosis or necrosis are inconsistently described, and some cases of cell proliferation have also been reported [26][27][28].
Concerning the evolution of the symptomatology, the data are even more rare and appear to suggest a lull in symptoms during pregnancy [7,11,[29][30][31]. The best data concerning the evolution of symptoms after pregnancy are reported by a recent retrospective study by Alberico et al. involving 131 women interviewed before and two years after pregnancy [14]. The authors' findings favor an overall improvement of symptoms during the long term, but nevertheless indicate the persistence or the reappearance of at least one symptom of moderate or severe intensity in 84% of participants. At the same time, the authors noted a modest improvement in quality of life and no improvement in sexual function.
Our study reports qualitative data that are broadly transferable to these findings and thus contribute to the current trend relativizing the impact of pregnancy on the long-term outcome of patients [12]. As the majority of the women who participated in our study reported, the myth of pregnancy as a treatment or principle of management of endometriosis still appears to be largely supported among health professionals treating endometriosis. Not only is there no data in the scientific literature to support the claim that pregnancy is a sustainable way of improving the life and health of women with endometriosis, but this false claim appears to have a negative impact. In fact, according to participants' comments reported in our study, this assertion appears to be the source of false hope for women, resulting in a delay in resumption of hormonal treatment for endometriosis and a greatly degraded experience of the reappearance of symptoms. There is no doubt that pregnancy is an unavoidable and central issue in the care plan of patients with endometriosis. These women must be informed early on of the risk of infertility and must be supported in their pregnancy planning. We agree with Brigitte Leeners and Cynthia M. Farquhar in the notion that the decision to become pregnant should not be influenced by the positive or negative effect on the evolution of endometriosis [12].

Conclusion
The results of this qualitative study suggest that a first pregnancy obtained by IVF gives endometriosis patients the temporary illusion of a cure. The widespread myth that a pregnancy will lead to permanent improvement of endometriosis symptoms has deleterious consequences for women's experiences at the time of symptom recurrence. More data are needed to understand the exact influence of pregnancy on the long-term evolution of the symptomatology.